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By Bob Keaveney | August 31, 2011

In case you've been wondering how little influence physicians hold in Washington these days, consider how the triple-blow of health reform, deficit cutting, and ordinary Medicare spending adjustments will likely affect you.

For starters, wait until you get a load of Medicare's new Independent Payment Advisory Board. Very little notice has been given to this powerful new board created by the health reform act, but that will soon change. Its job is to help a spendthrift Medicare become fiscally sustainable. Unlike its predecessor — a board called MedPac, whose cost-cutting recommendations to Congress are just that — the new group's actions become law unless explicitly overturned by Congress, and its remedies will mostly be limited to cutting payments to doctors.

What's happening now to American physicians is the result of a long-term cultural shift in the way society views you and your role in public life. Physicians, America has demoted you. Previous generations saw you as vital experts offering crucial advice and service to individuals and families, mostly via the private sector. Today, doctors are viewed as anonymous "providers" in a healthcare system that is better understood as a quasi-public utility than as a private industry.

Many of you have noticed that shift for years now and have resented it (my inbox is proof of that), but the practical effects have been minor compared to what you'll see in the environment brought on by health reform, which represents, I think, the final piece in your transformation from vital professional to public utility employee.

Where were physicians' voices during the debate over how to shape reform? You were talking, but, alas, you weren't (and still aren't) speaking with one voice, and in any case our elected leaders weren't listening. Doctors again took it on the chin in August, when Congress at last resolved its protracted debate over the debt ceiling by creating yet another deficit-reduction commission. This one will be charged with finding $1.2 trillion worth of debt reduction (at minimum) by Thanksgiving. Failure triggers draconian cuts, including a 2 percent reduction in payments to hospitals and physicians, amounting to $130 billion over 10 years. Perhaps the commission can avoid the trigger by agreeing to an actual proposal, but any such agreement would surely include Medicare cuts. Eric Zimmerman, a hospital industry lobbyist, told the Boston Globe that his clients are trying to decide which is worse, the automatic cuts "or whatever the committee recommends."

And all of it is on top of the 30 percent payment cut that doctors face in January as part of Medicare's usual process of reconciling its sustainable growth rate formula with its actual costs. That threatened cut has always been overturned by Congress at the 11th hour, usually replaced by a token payment increase. It’s an annual Washington tradition as predictable as the presidential pardoning of a Thanksgiving turkey. But this could be the year that conservatives, infused with budget-cutting zeal, might force real reductions.

There was a time when American physicians had real influence in Washington. That time has passed.